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0212612028 16:13 2094686186 ENG PAGE 01/01 <br /> �v I.1,.rd oacliay tnrerpnses, Inc JR93675424 p.2 <br /> San Joaquin County <br /> Envirememd Utgith Department <br /> 304 E.Weber Ave,Third Floor Stockton CA 93202 <br /> Telephone(204)468-3420 Fax(209)46&3433 <br /> Owner Statelments of Designated Underground Stomge T {(IST) Operator <br /> and Undel'standing of and CanVIiw=*ith DIST Requirements <br /> FavilityNeme.- SAW 3;;YR�rrt� .� N>~zA� L Facility ED A: <br /> Faci lily Address: Itcarsaa for Subnritti ibis Forgr <br /> ! <br /> St?E> t R7a,5— 4-iCSPZTAA_ 'R GRD ng mac'©'&'r <br /> VrA f-;- 14 C44 ttr!t� CA Ii Z 3 i �aneo of'Asxignawd Opemv, <br /> Facility PhoneZ .�. i-+�ee 4sfrr ^'?orvv� D Updo-Ceftifrc F- n D®fc <br /> IDesimailed UST®nera j2ds)for this FacWty <br /> Designated OperatoT's Nattae: -7dS E'PFI IkPkr.! E, lZdation w UST Facility(C nick One) <br /> $tai ,Name(VWeraufrom4r aw): art Fy u 4umcr CI (Vomtor ❑ E,mplo"t <br /> Designated Operator's PEtow.t,': ?-moi 36-7- PO 0 Seaioe Technician �''17rird,Party <br /> laramatiouol Gude CounKil C,aruificauion�i; Expimagn DqW.. 11/21 12.co 9 <br /> ALTERMATE <br /> rkmgmted Opendm'sName: Rdslim to UST Facility(07k tse) <br /> 2uAnessNawe(if dtffcnV9frenrah M)," 0 011-M 13 Opom O Entnlayoc <br /> DeAgmW Opctator's Phonic k 0 Urvice Tcchni*, Q T17ir&paAv <br /> lmtematioaal Code Council Cattillcation 11: Dom: <br /> ALTERNATE 2 (Op6onap <br /> Design ul Opcmtor s Names _ Relation to UST raciliey(C► <hho <br /> 3asia=Nam e(dfd))2r% to frr m 4ow). La {VMw 0 OPC r ❑ EmploYcc <br /> 005igaauxl Operators Phone 4: ❑ SaviceTee ' min 0 TWid-P w <br /> ieternati onal Code Council Cr ftificadion 9: r-.,qq atiou Dates <br /> NOTE;THE LOCAL REGULATORY AGENCY MUST BE NOTUIED OF ANY CHANGES TO THM <br /> MFORMATION'pVI;MTN 30 DAYS OF THE CHANGE. <br /> eertif�-that,for the facility indicated at the top of tuts page,the individital(s)listed above will <br /> serve as Designated UST Operator(s). The individual(s)a61ll conduct and docunumt monthly <br /> facility inspections;wd annual.'facility employee training,in accordance with California Code of i <br /> Regulations, title 23,section 2715(c)-(f). <br /> Furthermore,I!understmW and am in compliance with the reiluirements(statutes., <br /> regulations,and local or,din )applicable to underground Mrage tanks. <br /> NAM OF TAXA OWNER(Please Prin"t")':., <br /> SIGPiATU'RZ OF TAPITC®wNER: <br /> !' , —I e- <br /> DA'L'E: O . 'SP"ONEtk <br /> November 20(4 <br />